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Health Affairs Thematic Issue On Mental Health Care Explores U.S. Mental Health Care Trends, Comparative Effectiveness, Access For Veterans, And Supported Employment

Additional Articles Explore The Relationship Between Hospital Costs And Quality, Wealth Differences Between The Insured And Uninsured, And The Design Of Patient Assistance Programs

BETHESDA, Md., May 5, 2009 -- Many more people are using mental health services and U.S. mental health spending rose 65 percent in the past decade, but there is still a disturbingly large gap between access to care and quality of mental health care received. These are some of the findings discussed in the May/June issue of Health Affairs -- Mental Health Care: Better, Not Best -- released today. http://content.healthaffairs.org/content/vol28/issue3/

The issue explores key aspects of U.S. mental health care including the latest mental health care trends, comparative effectiveness research in mental health treatment, barriers facing veterans in need of mental health services, and supported employment as a means of helping Social Security disability program recipients with psychiatric disabilities earn incomes. The issue is funded by a grant from the MacArthur Foundation.

Mental health-related highlights from the issue are described below. Highlights on other topics follow.

• Doctors Prescribing More Psychotropic Medicines, Especially To Seniors

More health care providers are prescribing psychotropic medications to their patients, particularly to seniors, a finding that reflects an overall trend in improved access to mental health care, report Sherry Glied and Richard Frank. In an analysis of U.S. mental health care trends between 1996 and 2006, the two researchers found that the number of seniors receiving psychotropic drug prescriptions doubled since 1996. They attribute increased prescribing to the fact that primary care doctors have become more familiar with psychotropic medications and that lower-cost drugs have grown more widely available. http://content.healthaffairs.org/cgi/content/abstract/28/3/637

"Greater availability of medications to treat conditions like Alzheimer's and increased access to prescription drugs through the Medicare Modernization Act may have also played a role in doctors’ prescribing drugs to seniors," said Glied, Professor and Chair of Health Policy and Management, Mailman School of Public Health, at Columbia University.

Seventy-three percent more adults and 50 percent more children are also using psychotropic drugs, according to the study. Rather than a trend toward overprescribing, this trend reflects improved access as more insurance companies are offering mental health services and more psychiatrists are accepting health insurance, according to the authors. Children’s access has grown through the expansion of the Children’s Health Insurance Program (CHIP). The number of children diagnosed and treated for mental health conditions during primary care visits doubled between 1996 and 2006.

"It’s a mixed future for access to mental health care in our country," said Glied. "On one hand, the federal government is expanding protections like CHIP, which helps the neediest children. But on the other hand, the economic downturn may mean that more people lose their health insurance and will no longer be able to afford mental health care."

Although the authors found improved access to mental health care for many, challenges remain for more vulnerable populations. Treatment for elderly people with mental limitations that make it hard for them to conduct activities of daily living -- such as dressing, eating, or bathing -- without assistance declined between 1996 and 2006. In addition, more people with serious mental illnesses are imprisoned or incarcerated. The authors estimate that 7 percent of people with persistent mental illnesses are put in jail or prison every year.

In a related study, Richard Frank, Professor of Health Economics at Harvard Medical School, and colleagues found that mental health care spending grew 17 percent from 2001 to 2003, exceeding historical averages, which the authors attribute to increased spending on new prescription drugs. http://content.healthaffairs.org/cgi/content/abstract/28/3/649

• Improving Mental Health Treatment Through Comparative Effectiveness Research

Although this nation spends a considerable amount on mental health care, it is unclear what the return is on its investment. Two new studies point to a dearth of research aimed at identifying the most effective and cost-effective treatments, and suggest that more comparative effectiveness research in this area could help. The recently enacted American Recovery and Reinvestment Act (ARRA) included $1.1 billion for such research, but Congress did not specify how the findings should be used.

Philip Wang and colleagues report that about half of Americans suffering from mental illnesses in a given year do not receive treatment and that another quarter get treatment that is not consistent with evidence-based guidelines. Some patients may be receiving inappropriate treatments simply because doctors lack the evidence to make an informed decision about care. Consequently, doctors must rely not only on the scientific literature, but on advice from colleagues and anecdotal information, according to authors. http://content.healthaffairs.org/cgi/content/abstract/28/3/783
Wang, the Acting Deputy Director of the National Institute of Mental Health, explores whether more investment is needed in studies that compare treatments and therapies to help identify the best way to treat a given condition like schizophrenia or hard-to-treat depression. "Such research could have the potential to identify treatments that are effective and cost-effective. That’s knowledge that could help patients, clinicians, and other decisionmakers," he said.

A second study by Marcela Horvitz-Lennon, a researcher at the Western Psychiatric Institute and Clinic in Pittsburgh, and colleagues suggests that patients don’t always get the right treatments even when enough information about best practices is available. Financial incentives, the regulatory environment, the quality of the mental health workforce, and pharmaceutical marketing strategies have a significant impact on providers’ decisions regarding which treatments to use. Underuse of effective treatments and overuse of treatments without evidence of effectiveness undermine quality of care and lead to poor patient outcomes. For people with severe mental illnesses, this may mean increasing isolation, repeated hospitalizations, inability to secure or hold a job, and even suicide, the authors said. http://content.healthaffairs.org/cgi/content/abstract/28/3/701

• Veterans Face Challenges To Obtaining High-Quality Mental Health Care

In a new study, RAND Corporation researchers Audrey Burnam and colleagues point out recent evidence that many military service members and veterans get inadequate treatment or no care at all for post-traumatic stress disorder (PTSD) and depression. A large infusion of new funds into the Department of Defense (DOD) and Veterans Health Administration (VHA) in recent years is supporting continued efforts to improve the capacity and quality of mental health care in these systems. The authors argue that national efforts should be extended to better prepare community health care providers, because as veterans reintegrate into their home communities, many rely on private practitioners available through employer-based or DOD health plans. Changes by DOD are also needed to reduce institutional and cultural barriers to seeking mental health care, especially for active-duty service members. http://content.healthaffairs.org/cgi/content/abstract/28/3/771

"We have a tremendous opportunity to help veterans get the care they need and deserve," said Burnam, Behavioral Scientist at RAND and lead author of the study. "But federal, state, and local leadership will be needed to engage health care plans, mobilize support resources in local communities for veterans, and ensure that those who seek mental health care are provided effective treatments," she said.

The authors suggest standards and training to increase use of evidence-based treatment practices for combat-related mental disorders in communities. For military service members, the authors recommend a confidential mental health treatment option to overcome barriers to their seeking help.

• Helping Mentally Ill People Find Jobs Could Save Federal Government $368 Million A Year
Social Security disability programs have been widely criticized as too costly and too inclined to relegate recipients to lifelong poverty and dependency. But a national program to help mentally ill people on Social Security disability programs find jobs could spur greater independence while saving the federal government $368 million annually, according to a study by Robert Drake of Dartmouth Medical School and colleagues. http://content.healthaffairs.org/cgi/content/abstract/28/3/761

Approximately 27 percent of people who are receiving Social Security Disability Insurance (SSDI) benefits are mentally ill. Surveys show that up to 70 percent of people with mental illnesses want to work. Drake and his coauthors say that a national "supported employment" program would help these people, as well as those with mental illnesses who qualify for the separate Supplemental Security Income (SSI) program, to earn incomes that could total up to $1.6 billion a year.

The authors say that supported employment that couples employment counseling with mental health services has been proved to improve participants’ financial security. Approximately two-thirds of enrollees in supported employment programs find competitive employment. "Giving people with mental disabilities the power to build financial security will help improve their quality of life significantly by encouraging self-sufficiency and building self-esteem, which can ultimately help move their treatment forward as well," says Drake, Psychiatry Professor at Dartmouth Medical School and lead author of this study.

Issue highlights on subjects other than mental health are described below.

• Low-Cost Hospitals Provided Modestly Worse Care For Common Conditions

Many have advocated using a hospital’s risk-adjusted costs as a measure of efficiency. However, Ashish Jha of Harvard and coauthors found that low-cost hospitals provided modestly worse care than high-cost hospitals for acute myocardial infarction (heart attack) and congestive heart failure. Low-cost hospitals were more likely to be for-profit than their high-cost counterparts, according to Jha, an associate professor at the Harvard School of Public Health, and coauthors. Low-cost hospitals also treated, on average, a higher fraction of Medicare patients and had lower nurse-to-patient ratios. "As payers increasingly reward greater ‘efficiency’ or lower costs, they need to exercise caution to ensure that they are not inadvertently encouraging worse care," the authors conclude. http://content.healthaffairs.org/cgi/content/abstract/28/3/897

• Differences In Wealth, Not Just Income, Affect The Affordability Of Health Coverage

Differences in wealth are an important determinant of the affordability of health insurance, undermining the notion that many people are uninsured by choice, say researchers from the Agency for Healthcare Research and Quality (AHRQ). Senior AHRQ economist Didem Bernard and coauthors say that income differences do not fully reflect differences in purchasing power between the insured and the uninsured. This is particularly true for those without access to employer-sponsored insurance who must seek coverage in the individual market, according to Bernard and colleagues. In 2002-03, median net wealth among families with nongroup insurance was 34.6 times that of the uninsured families without access to employer coverage ($105,819 versus $3,057). In contrast, the median income of families who purchased nongroup health insurance was $41,086 -- only 2.3 times greater than the median income of $17,690 for families without access to employer coverage who were uninsured. http://content.healthaffairs.org/cgi/content/abstract/28/3/887

• Complexity, Lack Of Transparency Hinder Effectiveness Of Patient Assistance Programs

Drug company-sponsored patient assistance programs (PAPs) provide access to brand-name medications at little or no cost, but in a 2007 survey, Harvard Medical School Assistant Professor Niteesh Choudhry and colleagues found several features of PAPs that could limit their usefulness. Application processes were generally complex, and most programs covered only one or two drugs. Moreover, only 4 percent of surveyed PAPs disclosed how many patients they had directly helped, and more than half would not reveal their income eligibility criteria. The authors suggest several possible steps to increase transparency in PAPs, including calling for greater collection of information to help better understand the role of PAPs in assisting patients whose coverage is inadequate.

In Perspectives, Ken Johnson of Pharmaceutical Research and Manufacturers of America (PhRMA), http://content.healthaffairs.org/cgi/content/abstract/28/3/835, and Myrl Weinberg of the National Health Council, http://content.healthaffairs.org/cgi/content/abstract/28/3/839, take issue with many of Choudhry and coauthors’ conclusions, and Choudhry and colleagues respond. http://content.healthaffairs.org/cgi/content/abstract/28/3/843


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